Erika C.

Cacatian

Title: The development of clinical nursing practice guideline for initial assessment in multiple injury
patients admitted to trauma ward

Authors: Wipa Sae-Sia, RN, PhD, Praneed Songwathana, RN, PhD, and Pornpen Ingkavanich, RN, MNS

Journal: Australasian Emergency Nursing Journal

I Reason for choosing the Topic

I chose this topic because a clinical nursing practice guideline for initial assessment in
multiple injury patients admitted to trauma wards in the Philippines has not been established
yet. I want to share this journal wherein a tertiary hospital in Thailand developed their our
CNPG in the hope of partaking also ideas on how our country can create its own CNPG for
the betterment of our patients and improvement of nursing care in trauma wards.

II Main Problem
Advanced Trauma Life Support (ATLS) is a well-known guideline that was developed in the
United States of America.18 and has been translated into many languages around the world.
ATLS was developed to guide physicians and nurses in accurately performing the assessment
and treatment of multiple trauma patients. There are four steps included in ATLS: primary
survey, resuscitation, secondary survey, and definitive care.18 However, there are currently
no guidelines for the rapid assessment and management of patients with multiple trauma
admitted to secondary hospitals, such as provincial hospitals, in Thailand. The purpose of this
study was therefore, to develop and evaluate the effectiveness of a clinical nursing practice
guideline (CNPG) for the initial assessment of multiple trauma patients admitted to the
trauma ward in Songkhla Hospital in southern Thailand. The main outcome measures were:
(1) compliance with the use of the CNPG, (2) nurses satisfaction in implementing the CNPG,
and (3) the percentage of missed injuries detected through the use of the CNPG.

III Research Methodology

A two-step exploratory approach was employed in this study. The first step was the
development of the contents of the initial assessment guideline for multiply injured patients.
The second step was to evaluate the effectiveness of the CNPG developed. The process of
developing the guideline was based on the process published by the Australian National
Health and Medical Research Council (NHMRC). The CNPG was implemented by all 18
registered nurses who worked in the trauma ward, Songkhla Hospital with 34 multiple trauma
patients between the middle of May and the first week of June, 2009.

Intervention (CNPG)
There were two steps in developing the intervention (CNPG). The first step was the
development of the guideline based on the NHMRC12 process. The process of validating the
contents of the guideline began by assembling an expert panel. The expert panel consisted of
one physician, two Master-prepared nurses working in the trauma ward, a head nurse from
the trauma ward, and two nursing researchers working in the trauma area. A working group
consisting of the members of the expert panel analyzed the levels of evidence used in the
ATLS. It was found that the evidence used for recommendations for secondary assessment in
the ATLS were Level 2 to Level 5 in which Level 2 evidence is from randomized control trial
studies either with or without a control group and single prospective studies, and Level 5
evidence is expert opinion. In addition, the ATLS was evaluated using the Appraisal of
 Guidelines Research and Evaluation (AGREE) instrument which is a set of assessment
criteria developed by the AGREE collaboration committee to evaluate the quality of practice
guidelines. The ATLS guidelines quality score exceeded 60% based on the AGREE criteria,
which is considered to be an acceptable score. However, a major gap in ATLS is that it does
not include the assessment of the psychological status of multiple trauma patients.
Psychological problems are an important aspect of the initial assessment of patients suffering
multiple trauma. Therefore, a psychological assessment was included in the draft of the
guideline used in this study. The psychological assessment included assessments of fear,
anger, paranoia, anxiety, and uncertainty. Next, a draft CNPG for the initial assessment of
multiply injured patients was prepared. This draft CNPG was reviewed by the same group of
six experts. After revision of the draft CNPG based on the recommendations of the experts,
the draft guideline was assessed for content validity. The draft CNPG was also checked for
inter-rater reliability by three pairs of registered nurses. The sections of the CNPG consisted
of (1) demographic data, (2) patients history, using AMPLE (allergies, medication, past
history, last meal, event/environment related to injuries), (3) operational procedure/treatment,
(4) head to toe physical examination, (5) estimated blood loss, (6) pain assessment, (7)
laboratory information, (8) psycho-social assessment, (9) functional health assessment, and
(10) nursing diagnosis identification.

IV Summary of Findings
It was found that 15 nurses felt that overall the ten sections of the CNPG were easy to comply
with. However, 13 reported that only eight sections of the CNPG were feasible to be
implemented in practice. Fourteen nurses indicated a lower feasibility for the implementation
of the pain assessment component, particularly in traumatic brain injury patients who were
unconscious. In addition, five reported that the requirement of performing a head to toe
physical examination was not easy to comply with, especially when many new patients were
admitted during their shift. Most of the nurses reported that their satisfaction in implementing
the CNPG was at a high level (scores = 7 or 8) with three reporting their satisfaction at a
moderate level (scores = 46). Of the 34 patients with 55 diagnosed injuries included in this
study, 29 were male, 17 had minor injuries, seven had moderate to severe injuries and 10 had
severe to critical injuries. The most common diagnosis was traumatic brain injury. Of the 55
diagnosed injuries, eight were missed injuries detected while using the CNPG within 24
hours of ward admission. The most common missed injuries were clavicle fractures, fractured
ribs, ruptured spleen, a facial fracture, a lacerated wound in the scalp, and broken teeth.

V Conclusions
Multiple injuries may initially be missed despite primary and secondary surveys in EDs. The
CNPG used for the initial assessment of multiple injury patients admitted to the trauma ward,
which was developed in this study, was found to be useful in promoting the early detection of
missed injuries. The nurses compliance with the use of the CNPG and their satisfaction rate
in its use were found to be at high levels. Therefore, further studies at other institutions as
well as with more junior nursing staff are recommended to establish if this CNPG could be
more widely used for the initial re-assessment of multiple injury patients admitted to trauma
wards providing secondary level trauma care in Thailand.

VI Implications

Nursing Education
Nursing Practice

Nursing Research

Replication of this study with a larger sample in other trauma wards at other institutions and
with less experienced and more junior nursing staff is recommended to establish if the
findings of this study are generalizable to other contexts. Future studies should investigate the
factors which cause injuries to be missed and should measure patient outcomes, such as the
length of stay in hospital, and the morbidity and mortality rate of multiply injured patients
after the use of the CNPG. It is also recommended that future studies should employ
documentation audits to confirm the results of self-reported data on compliance with the
CNPG.